High-flow Nasal Cannula In Patients Research Articles

Exploring diaphragmatic response to high-flow nasal cannula in patients with COVID-19 pneumonia using ultrasound: a proof of concept study.

Recent studies have highlighted the recognition of diaphragmatic dysfunction as a significant factor contributing to respiratory disturbances in severely ill COVID-19 patients. In the field of noninvasive respiratory support, high-flow nasal cannula (HFNC) has shown effectiveness in relieving diaphragm dysfunction. This study aims to investigate the diaphragmatic response to HFNC in patients with COVID-19 pneumonia by utilizing ultrasound. This retrospective study was conducted in a medical-surgical intensive care unit (ICU) at a tertiary care center in Buenos Aires, Argentina (Sanatorio de Los Arcos) over a 16-month period (January 2021-June 2022). The study included patients admitted to the ICU with a diagnosis of COVID-19 pneumonia who were deemed suitable candidates for HFNC therapy by the attending physician. Diaphragm ultrasound was conducted, measuring diaphragmatic excursion (DE) both before and during the utilization of HFNC for these patients. A total of 10 patients were included in the study. A statistically significant decrease in respiratory rate was observed with the use of HFNC (p = 0.02), accompanied by a significant increase in DE (p = 0.04). HFNC leads to a reduction in respiratory rate and an increase in DE as observed by ultrasound in patients with COVID-19 pneumonia, indicating promising enhancements in respiratory mechanics. However, further research is required to validate these findings.

Patient Self-Proning with High-Flow Nasal Cannula Improves Oxygenation in ARDS Patients: A Randomized Clinical Trial

Abstract Background Acute respiratory distress syndrome is a severe lung disease caused by a variety of direct and indirect insults. It is characterized by acute onset of tachypnea, hypoxemia, and loss of lung compliance. Significant atelectasis is also frequently present. It is associated with increased length of stay in the intensive care unit (ICU), long hospital stay, higher hospital charges as well as increased morbidity and mortality. However, it can be treated if dealt with promptly. Objective This work aims to evaluate the effect of self-proning with a high-flow nasal cannula in patients with ARDS on oxygenation and incidence of intubation. Results High flow nasal cannula and Proning was effective in improving oxygenation of the mild ARDS patients and decreasing the incidence of intubation (11 patients intubated in group 1, 4 in group 2), mortality(35 survived in group 1,42 in group 2) and ICU stay in these patients. Conclusions HFNC AND PRONING succeeded in prophylaxis against intubation in mild ARDS patients in ICU. And they succeeded in decreasing ICU stay days and improving the outcome of mild ARDS patients. Example Trial registration: PACTR202204746577792. Registered 14 April 2022 - Retrospectively registered, http://www.pactr.org/PACTR202204746577792

A meta-analysis of the effects of transnasal high-flow oxygen therapy in gastrointestinal endoscopy.

This study aimed to systematically evaluate the clinical effects of using transnasal high-flow nasal cannula (HFNC) and conventional oxygen therapy (COT) in patients undergoing gastrointestinal endoscopy. A comprehensive literature search was conducted from 2004 to April 2024 to collect relevant studies on the application of HFNC in patients undergoing gastrointestinal endoscopy. Multiple Chinese and English databases, including China National Knowledge Infrastructure (CNKI), Wanfang Data, Web of Science, PubMed, and Cochrane Library, were searched systematically for randomized controlled trials (RCTs). Two researchers independently screened the literature, extracted data, and assessed the risk of bias in the included studies. RevMan 5.4 software was utilized for conducting the network meta-analysis. A total of 12 RCTs involving 3,726 patients were included. Meta-analysis results showed that HFNC reduced the incidence of hypoxemia and improved the minimum oxygen saturation (SpO2) compared with COT [odds ratio (OR) = 0.39, 95% confidence interval (CI): 0.29-0.53], [mean difference (MD) = 4.07, 95% CI: 3.14-5.01], and the difference was statistically significant. However, the baseline SpO2 levels and incidence of hypercapnia were not statistically significantly different between the HFNC and COT groups [MD = -0.21, 95% CI: -0.49-0.07]; [OR = 1.43, 95% CI: 0.95-2.15]. In terms of procedure time, the difference between HFNC and COT was not statistically significant, and subgroup analyses were performed for the different types of studies, with standard deviation in the gastroscopy group (MD = 0.09, 95% CI: -0.07-0.24) and the endoscopic retrograde cholangiopancreatography group (MD = 0.36, 95% CI: -0.50-1.23). The results demonstrated a significant reduction in the adoption of airway interventions in the HFNC group compared to the COT group (OR = 0.16, 95% CI: 0.05-0.53), with a statistically significant difference; this result was consistent with those of the included studies. The application of HFNC improves the incidence of hypoxemia, enhances oxygenation, and reduces airway interventions during gastrointestinal endoscopy. However, HFNC does not significantly affect baseline SpO2, hypercapnia, or procedure time. The limitations of this study must be acknowledged, and further high-quality studies should be conducted to validate these findings.

DCROX and ROX Indices Predict Clinical Outcomes in Patients with COVID-19 Pneumonia Treated with High-Flow Nasal Cannula Oxygen Therapy.

High-flow nasal cannula (HFNC) therapy is a common respiratory support in patients with COVID-19 pneumonia. Predictive tools for the evaluation of successful weaning from HFNC therapy for COVID-19 pneumonia have been limited. This study aimed to develop a new predictor for weaning success from HFNC treatment in patients with COVID-19 pneumonia. We conducted a retrospective cohort study at Thammasat University Hospital, Thailand. Patients with COVID-19 pneumonia requiring HFNC therapy from April 2020 to September 2021 were included. The ROX index was defined as the ratio of oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) to respiratory rate. The CROX index was defined as the ratio of C-reactive protein (CRP) to the ROX index. dCROX was defined as the difference in CROX index between 24 hours and 72 hours. Weaning success was defined as the ability to sustain spontaneous breathing after separation from HFNC without any invasive or noninvasive ventilatory support for ≥48 hours or death. A total of 106 patients (49.1% male) were included. The mean age was 62.1 ± 16.2 years. Baseline SpO2/FiO2 was 276.1 ± 124.8. The rate of HFNC weaning success within 14 days was 61.3%. The best cutoff value of the dCROX index to predict HFNC weaning success was 3.15 with 66.2% sensitivity, 70.7% specificity, and an area under the ROC curve (AUC) of 0.71 (95% CI: 0.59-0.81, p < 0.001). The best cutoff value of the ROX index was 9.13, with 75.4% sensitivity, 78.0% specificity, and an AUC of 0.79 (95% CI: 0.69-0.88, p < 0.001). ROX index has the highest accuracy for predicting successful weaning from HFNC in patients with COVID-19 pneumonia. dCROX index is the alternative tool for this setting. However, a larger prospective cohort study is needed to verify these indices for determining separation from HFNC therapy. This trial is registered with TCTR20221107004.

Comparison of ROX, HROX, and delta-HR indices to predict successful weaning from high-flow oxygen therapy in hospitalized patients with COVID-19 pneumonia.

High-flow nasal cannula (HFNC) therapy is commonly used to treat acute respiratory failure in patients with COVID-19 pneumonia. However, predictors of successful weaning from HFNC in these patients has not been investigated. To assess predictors of successful separation from HFNC in patients with COVID-19 pneumonia. We conducted a retrospective cohort study at a university hospital in Thailand. Patients with COVID-19 pneumonia requiring HFNC therapy between April 2020 and June 2022 were included. ROX index was defined as the ratio of oxygen saturation (SpO2) / fraction of inspired oxygen (FiO2) to respiratory rate. Heart-ROX (HROX) index was defined as ROX multiplied by heart rate (HR) improvement. HR improvement (delta-HR) was defined as a percentage of the difference between the baseline HR and the morning HR at HFNC weaning day 1 divided by the baseline HR. Weaning success was defined as ability to sustain spontaneous breathing after separation from HFNC without any invasive or non-invasive ventilatory support for ≥48 hours or death. A total of 164 patients (54% male) were included. Mean age was 61.1±16.1 years. Baseline SpO2/FiO2 was 265.3±110.8. HFNC weaning success was 77.4%. The best cut-off value of ROX index to predict HFNC weaning success was 7.88 with 100% sensitivity, 97.3% specificity, and area under the ROC curve (AUC) of 0.98 (95% CI: 0.937-1.000, p<0.001). The best cut-off value of delta-HR 3.7 with 88.2% sensitivity, 75.7% specificity, and AUC of 0.83 (95% CI: 0.748-0.919, p<0.001). The best cut-off value of HROX index was 59.2 with 88.2% sensitivity, 81.1% specificity, and AUC of 0.89, (95% CI: 0.835-0.953, p<0.001). The ROX index has the highest accuracy for predicting successful weaning off HFNC treatment in patients with COVID-19 pneumonia. While HROX and delta-HR indices can serve as alternative tools, it is recommended to verify these indices and determine the optimal cut-off value for determining separation from HFNC therapy through a large prospective cohort study. Clinicaltrials.in.th number: TCTR20221108004.

CPAP vs HFNC in treatment of patients with COVID-19 ARDS: A retrospective propensity-matched study.

Previous studies exploring the application of noninvasive ventilation or high-flow nasal cannula in patients with COVID-19-related acute respiratory distress syndrome (ARDS) have yielded conflicting results on whether any method of respiratory support is superior. Our aim is to compare the efficacy and safety of respiratory therapy with high-flow nasal cannula and noninvasive ventilation with continuous positive airway pressure in treatment of COVID-19-related ARDS. This is a retrospective cohort study based on data from patients who received respiratory support as part of their treatment in the COVID intensive care unit at the University Hospital Centre Zagreb between February 2021 and February 2023. Using propensity score analysis, 42 patients treated with high-flow nasal cannula (HFNC group) were compared to 42 patients treated with noninvasive ventilation with continuous positive airway pressure (CPAP group). Primary outcome was intubation rate. Intubation rate was 71.4% (30/42) in the HFNC group and 40.5% (17/42) in the CPAP group (p = 0.004). Hazard ratio for intubation was 3.676 (95% confidence interval [CI] 1.480 to 9.232) with the HFNC versus CPAP group. Marginally significant difference in survival between the two groups was observed at 30 days (p = 0.050) but was statistically significant at 60 days (p = 0.043). Respiratory support with high-flow nasal cannula and noninvasive ventilation with continuous positive airway pressure yielded significantly different intubation rates in favour of continuous positive airway pressure. The same patients also had better 30-day and 60-day survival post-admission.

Non-invasive ventilation strategy for patients with acute respiratory failure in emergency department – a systematic review

Background: We sought to assess the efficacy of noninvasive positive pressure ventilation against high-flow nasal cannula in patients experiencing acute respiratory failure, as they may be necessary if the respiratory insufficiency is more severe. Method: We conducted a thorough search from 2013 to 2023 throughout EMBASE, Cochrane library, MEDLINE, and CINAHL database. We incorporated randomized control trials that contrasted adult patients with ARF with HFNC and NIPPV. We collected data on trial features, demographics, intervention and control arm management, and clinical outcome outcomes of interest. For the economic outcomes, we collected data on the analytical approach, research design, time horizon, study viewpoint, and study features. Results: We included 6 RCTs with a total of 1421 patients after evaluating 612 citations. Patients in RCTs ranged in number from 30 to 791. Of the six RCTs, one was published after being abstracted. Overall, HFNC was compared to facemask NIPPV in five investigations, and to both facemasks in one research. Patients with hypoxic respiratory failure caused by the corona virus were included in two investigations, along with those with mixed hypoxia respiratory failure, immunocompromised patients by themselves, and one study with mixed respiratory failure. Conclusion: While there is conflicting evidence about the impact of HFNC and NIPPV on mortality in hospitalized patients with hypoxemic respiratory failure, they may be equally successful in lowering the requirement for intubation.

Efficacy of high-flow nasal cannula in patients with acute heart failure: a systematic review and meta-analysis

BackgroundAcute heart failure (AHF) is often associated with diffuse insufficiency and arterial hypoxemia, requiring respiratory support for rapid and effective correction. We aimed to compare the effects of high-flow nasal cannula(HFNC) with those of conventional oxygen therapy(COT) or non-invasive ventilation(NIV) on the prognosis of patients with AHF.MethodsWe performed the search using PubMed, Embase, Web of Science, MEDLINE, the Cochrane Library, CNKI, Wanfang, and VIP databases from the inception to August 31, 2023 for relevant studies in English and Chinese. We included controlled studies comparing HFNC with COT or NIV in patients with AHF. Primary outcomes included the intubation rate, respiratory rate (RR), heart rate (HR), and oxygenation status.ResultsFrom the 1288 original papers identified, 16 studies met the inclusion criteria, and 1333 patients were included. Compared with COT, HFNC reduced the intubation rate (odds ratio [OR]: 0.29, 95% CI: 0.14–0.58, P = 0.0005), RR (standardized mean difference [SMD]: -0.73 95% CI: -0.99 – -0.47, P < 0.00001) and HR (SMD: -0.88, 95% CI: -1.07 – -0.69, P < 0.00001), and hospital stay (SMD: -0.94, 95% CI: -1.76 – -0.12, P = 0.03), and increase arterial oxygen partial pressure (PaO2), (SMD: 0.88, 95% CI: 0.70–1.06, P < 0.00001) and oxygen saturation (SpO2 [%], SMD: 0.70, 95% CI: 0.34–1.06, P = 0.0001).ConclusionsThere were no significant differences in intubation rate, RR, HR, arterial blood gas parameters, and dyspnea scores between the HFNC and NIV groups. Compared with COT, HFNC effectively reduced the intubation rate and provided greater clinical benefits to patients with AHF. However, there was no significant difference in the clinical prognosis of patients with AHF between the HFNC and NIV groups.Trial registrationPROSPERO (identifier: CRD42022365611).

A simple nomogram for predicting failure of high-flow nasal cannula in patients with acute hypoxemic respiratory failure

Objective: To evaluate the predictive efficacy of a nomogram in patients with acute hypoxemic respiratory failure (AHRF) undergoing treatment with a high-flow nasal cannula (HFNC). Methods: We conducted a retrospective observational study of patients with AHRF who received HFNC treatment. Data on complications, vital signs on the first day after enrollment, use of vasoactive drugs, Glasgow Coma Scale scores, and clinical respiratory parameters (respiratory rate, pulse oximetry oxygen saturation, and fraction of inspired oxygen) were meticulously recorded. The risk ratio for HFNC failure was computed using an online calculator. Results: Overall, 62 patients were included, of which 29 (46.77%) experienced HFNC failure. No significant differences were observed in age, sex, body mass index, complications, or sequential organ failure assessment scores between the two groups. However, compared with those who responded positively to HFNC treatment, individuals experiencing HFNC failure demonstrated a significant increase in acute physiology and chronic health evaluation Ⅱ scores [ (15.15±5.01)score vs. (21.00±5.76)score; P<0.001 ]. Furthermore, HFNC treatment failure was associated with significantly higher ICU mortality rates [0 vs. 34.48%(10/29),P<0.01] and in-hospital mortality rates [3.03%(1/33) vs. 37.93%(11/29),P<0.01], as well as a marked prolongation of ICU stay [6(4,10)d vs. 11(6,17)d, P=0.012]. In the failure group, the nomogram-derived risk ratio was 0.80±0.18, which was significantly higher than that in the success group (0.65±0.18; P=0.009). The area under the receiver operating characteristic curve of the nomogram for predicting HFNC failure was 0.76, with a sensitivity of 54.8% and a specificity of 93.6%. Conclusion: The nomogram, along with the online calculator, offers a straightforward and effective means for assessing the risk of treatment failure in patients with AHRF undergoing HFNC therapy.

Home high flow nasal cannula for chronic hypercapnic respiratory failure in COPD: A systematic review and meta-analysis

BackgroundChronic Obstructive Pulmonary Disease (COPD) with chronic hypercapnia is usually treated with non-invasive ventilation (NIV). High flow nasal cannula (HFNC) may be an appropriate alternative. However, the efficacy of HFNC in COPD patients with chronic hypercapnia is yet to be optimally summarized. MethodsWe conducted a systematic review and meta-analysis using random effects with inverse variance methods. Randomized controlled trials involving adult COPD patients initiated on HFNC for at least one month were included. Outcomes of interest were all-cause mortality, acute exacerbations, hospitalizations, and change in St. George Respiratory Questionnaire (SGRQ). We assessed the risk of bias using ROB 2.0 and assessed the quality of the evidence using GRADE. ResultsWe included four randomized trials involving 440 patients. HFNC probably reduces acute exacerbations compared to standard care (RR 0.77 [95 % CI 0.66 to 0.89]; moderate certainty), suggesting 69 fewer acute exacerbations per 1000 patients. HFNC may reduce hospital admissions (RR 0.87 [95 % CI 0.69 to 1.09]; low certainty) and may lower the SGRQ score (MD 8.12 units lower [95 % CI 13.30 to 2.95 lower]; low certainty). However, HFNC may have no effect on mortality (RR 1.22 [95 % CI 0.64 to 2.35]; low certainty). ConclusionHFNC probably reduces acute exacerbations and might reduce hospital admissions in COPD patients with chronic hypercapnia. However, its effect on mortality is uncertain. Future larger RCTs with longer follow-up periods are recommended to provide more robust evidence on the efficacy of HFNC in patients with COPD.

Feasibility, safety and efficacy of COVID-19 severe acute respiratory distress syndrome management without invasive mechanical ventilation.

COVID-19 acute respiratory distress syndrome (ARDS) is often managed with mechanical ventilation (MV), requiring sedation and paralysis, with associated risk of complications. There is limited evidence on the use of high flow nasal cannula (HFNC). We hypothesized that management of COVID-19 ARDS without MV is feasible. Included were all adult patients diagnosed with COVID-19 ARDS, with PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 at admission, and whose management was initially performed without MV. We evaluated need for intubation during ICU stay, mortality and hospital/ICU length of stay (LOS). Out of 118 patients, 41 were managed only with HFNC from hospital admission (and at least during first 24 hours in ICU) and had a PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 (72.9±13.0). 29/41 patients never required MV: 24 of them survived and were discharged home. Their median ICU LOS was 11 (7-17) days, and their hospital LOS was 29 (18-45) days. We identified PaO<inf>2</inf>/FiO<inf>2</inf> ratio at ICU admission as the only significant predictor for need for MV during ICU stay. We also identified age, length of non-invasive respiratory support before ICU admission, mean value of PaO<inf>2</inf>/FiO<inf>2</inf> ratio during first half and whole ICU stay as predictors of mortality. It is safe to monitor in ICU and use HFNC in patients affected by COVID-19 ARDS who initially present data suggesting an early need for intubation. The 41 patients admitted with a PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 and initially treated only with HFNC show a 22% mortality that is in the lower range of what is reported in recent literature.

The use of respiratory rate-oxygenation index to predict failure of high-flow nasal cannula in patients with coronavirus disease 2019-associated acute respiratory distress syndrome: A retrospective study.

Patients with mild-to-moderate coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS) can be treated with a high-flow nasal cannula (HFNC). The use of the respiratory rate-oxygenation (ROX) index, calculated as the ratio of oxygen saturation (SpO2)/fractional oxygen (FiO2) to respiratory rate, in the first few hours after HFNC initiation can help identify patients who fail HFNC therapy later. However, few studies have documented the use of the ROX index during the period of HFNC therapy. Therefore, we aimed to demonstrate the diagnostic performance of the ROX index when calculated throughout the HFNC therapy period and to determine the best cut-off point for predicting HFNC failure. We conducted a retrospective study of patients with COVID-19-associated ARDS who commenced HFNC at the Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand, between April 1 and August 30, 2021. We calculated the ROX index every 4 h throughout the HFNC therapy period and defined HFNC failure as a subsequent endotracheal tube intubation. The performance of the ROX index was analyzed using the area under the receiver operating characteristic curve (AUC). We applied the ROX index ≤ 4.88 to predict HFNC failure and obtained a new ROX cut-off point using Youden's method. In total, 212 patients with COVID-19 treated with HFNC were included in the study. Of these, 81 patients (38.2%) experienced HFNC failure. The ROX index ≤ 4.88 demonstrated a reasonable performance in predicting HFNC failure (AUC, 0.77; 95% confidence interval [CI], 0.72-0.83; p<0.001). However, compared with the original cut-off point of ≤ 4.88, the new ROX index cut-off point of ≤ 5.84 delivered optimal performance (AUC, 0.84; 95% CI, 0.79-0.88; p<0.001), with a significantly better discriminative ability (p = 0.007). In conclusion, a ROX index ≤ 5.84 was found to be optimal for predicting HFNC failure in patients with COVID-19-associated ARDS.

Patients self-proning with high-flow nasal cannula improves oxygenation in mild ARDS patients: a randomized clinical trial

Background &amp; Objective: Acute respiratory distress syndrome (ARDS) is characterized by the acute onset of tachypnea, hypoxemia, and loss of lung compliance. Clinicians have employed various means to improve oxygenation in these patients. We evaluated the effect of self-proning with a high-flow nasal cannula in patients with ARDS on oxygenation and the incidence of intubation. Methodology: Ninety patients, aged above 18 y old, patients with BMI below 30 kg/m2, from both genders, suffering from COVID-19 and mild ARDS, participated in this prospective, randomized, double-blind clinical trial at Ain Shams University hospitals. Participants were allocated into two equal groups; Group 1: Patients were subjected to HFNC with a target SpO2 ≥ 90% with FiO2 &lt; 0.6. Group 2: Patients were subjected to HFNC with a target of SpO2 &gt; 90% with FiO2 ≤ 0.6, and combined with self proning. Upon ICU admission, age, weight, BMI, sex, baseline PcO2/FiO2 (P/F) ratio, baseline SpO2 and baseline heart rate were noted. During ICU stay, hemodynamic data and respiratory rate, ABG’s were recorded on admission and every six hours after therapy 6, 12, 24, 48, and 96 h till the patient was discharged from ICU. CXR was obtained on admission and at 24 h, and assessed by Berlin criteria. Assuming a rate of intubation of 50% in the group without prone position setting power at 80% and alpha error at 0.05, a sample size of 45 patients per group was needed. Results: HFNC with proning was effective in improving oxygenation of the mild ARDS patients and decreasing the incidence of intubation; 11 patients in Group 1 and 4 in Group 2 needed to be intubated. Regarding mortality 35 patients survived in Group 1 compared to 42 in Group 2. The median ICU stay was significantly shorter in Group II, 12 (10–12) days compared to Group I, 19 (18–21); P = 0.000. Conclusion: The use of high-flow nasal cannula and proning reduced the frequency of intubation in mild ARDS patients in ICU, and also decreased the ICU stay and improved the outcome of patients with mild ARDS. Abbreviations: ARDS: Acute Respiratory Distress Syndrome; ICU: Intensive Care Unit; HFNC: High-Flow Nasal Cannula; NIV: Non-Invasive Ventilation Key words: Acute Respiratory Distress Syndrome; COVID-19; High Flow Nasal Cannula; Proning. Nasrallah BZN, et al Patients self-proning with high-flow nasal cannula www.apicareonline.com 352 Open access attribution (CC BY-NC 4.0) Citation: Nasrallah BZN, Mahmoud MS, Abdallah ElGendy HM, Youssri Mahmoud NM, Aly ElGendy MAE. Patients self-proning with high-flow nasal cannula improves oxygenation in ARDS patients: a randomized clinical trial. Anaesth. pain intensive care 2023;27(3):351−355; DOI: 10.35975/apic.v27i3.2079 Received: November 23, 2022; Reviewed: December 22, 2022; Accepted: April 08, 2023

Respiratory Care Management of COPD Exacerbations.

A COPD exacerbation is characterized by an increase in symptoms such as dyspnea, cough, and sputum production that worsens over a period of 2 weeks. Exacerbations are common. Respiratory therapists and physicians in an acute care setting often treat these patients. Targeted O2 therapy improves outcomes and should be titrated to an SpO2 of 88-92%. Arterial blood gases remain the standard approach to assessing gas exchange in patients with COPD exacerbation. The limitations of arterial blood gas surrogates (pulse oximetry, capnography, transcutaneous monitoring, peripheral venous blood gases) should be appreciated so that they can be used wisely. Inhaled short-acting bronchodilators can be provided by nebulizer (jet or mesh), pressurized metered-dose inhaler (pMDI), pMDI with spacer or valved holding chamber, soft mist inhaler, or dry powder inhaler. The available evidence for the use of heliox for COPD exacerbation is weak. Noninvasive ventilation (NIV) is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines. Robust high-level evidence with patient important outcomes is lacking for the use of high-flow nasal cannula in patients with COPD exacerbation. Management of auto-PEEP is the priority in mechanically ventilated patients with COPD. This is achieved by reducing airway resistance and decreasing minute ventilation. Trigger asynchrony and cycle asynchrony are addressed to improve patient-ventilator interaction. Patients with COPD should be extubated to NIV. Additional high-level evidence is needed before widespread use of extracorporeal CO2 removal. Care coordination can improve the effectiveness of care for patients with COPD exacerbation. Evidence-based practices improve outcomes in patients with COPD exacerbation.

Comparison of High Flow Nasal Therapy with Non-Invasive Ventilation and Conventional Oxygen Therapy for Acute Hypercapnic Respiratory Failure: A Meta-Analysis of Randomized Controlled Trials.

We aimed to evaluate whether high flow nasal cannula (HFNC) is an effective and safe method for adult patients with acute hypercapnic respiratory failure (AHRF). We searched the Cochrane Library, Embase, and PubMed databases from inception to August 2022 to obtain randomized controlled trials (RCTs) that compared HFNC with conventional oxygen treatment (COT) or non-invasive ventilation (NIV) in patients with AHRF, and then performed a meta-analysis. A total of ten parallel RCTs with 1265 individuals were identified. Of them, two studies compared HFNC with COT and eight studies compared HFNC with NIV. In terms of intubation rate, mortality, and arterial blood gas (ABG) improvement, HFNC showed comparable effects to NIV and COT. However, HFNC was more comfortable (mean difference [MD] -1.87, 95% confidence interval [CI] =-2.59, -1.15, P <0.00001, I2 =0%) and resulted in fewer adverse events (odds ratio [OR] 0.12, 95% CI=0.06, 0.28, P<0.00001, I2 = 0%), compared with NIV. In comparison to NIV, HFNC could significantly lower heart rate (HR) (MD -4.66, 95% CI=-6.82, -2.50, P <0.0001, I2 =0%), respiratory rate (RR) (MD -1.17, 95% CI=-2.03, -0.31, P =0.008, I2 =0%), and hospital stay length (MD -0.80, 95% CI=-1.44, -0.16, P =0.01, I2 =0%). NIV showed a decreased frequency in the treatment crossover rate, compared with HFNC in patients with pH<7.30 (OR 5.78, 95% CI=1.50, 22.31, P = 0.01, I2: not applicable). Contrary to COT, HFNC could considerably reduce the need for NIV (OR 0.57, 95% CI=0.35, 0.91, P=0.02, I2=0%). HFNC was effective and safe in patients with AHRF. However, in patients with pH <7.30, HFNC may result in a higher incidence of treatment crossover, compared with NIV. Compared to COT, HFNC may decrease the need for NIV in patients with compensated hypercapnia.

The use of high-flow nasal cannula in patients with chronic obstructive pulmonary disease under exacerbation and stable phases: A systematic review and meta-analysis

BackgroundHigh-flow nasal cannula (HFNC) has been increasingly utilized in patients with chronic obstructive pulmonary disease (COPD); however, the effects on reducing the need for intubation or reintubation remain unclear. ObjectivesWe aimed to investigate whether HFNC therapy was superior to conventional oxygen therapy (COT) or noninvasive ventilation (NIV) in patients with COPD. MethodsA literature search was performed in electronic databases until October 1st, 2022. The primary outcome was the need for intubation/reintubation. All analyses were performed using R (version 4.0.3) and STATA SE (version 15.1). ResultsWhen HFNC therapy was compared with NIV in patients with COPD under initial respiratory support and postextubation, no significant differences were found in the risk of intubation (RR 0.84, 95% CI 0.36 to 1.98) and reintubation (RR 1.35, 95% CI 0.73 to 2.50). Compared to NIV, HFNC therapy did not decrease the partial pressure of carbon dioxide or increase the partial pressure of oxygen to the fraction of inspired oxygen. However, HFNC therapy was associated with a lower incidence of skin breakdown (RR 0.52, 95% CI 0.39 to 0.69) and a higher comfort score (SMD 0.90, 95% CI 0.60 to 1.20) than NIV. When HFNC therapy was compared with COT during initial respiratory treatment for COPD exacerbation, a lower risk of treatment failure was found (RR 0.58, 95% CI 0.37 to 0.89). When HFNC therapy was compared with long-term oxygen therapy, quality of life (measured by SGRQ-C) was significantly improved (SMD -0.42, 95% CI -0.69 to -0.14). ConclusionHFNC therapy might be used as an alternative to NIV for COPD exacerbation with mild-moderate hypercapnia under close monitoring and is a potential domiciliary treatment for stable COPD.

Noninvasive Respiratory Support for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

To develop evidence-based recommendations for the Second Pediatric Acute Lung Injury Consensus Conference (PALICC) regarding the effectiveness of noninvasive respiratory support for pediatric acute respiratory distress syndrome (PARDS). These include consideration of the timing and duration of noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC), whether effectiveness varies by disease severity or by characteristics of treatment delivery, and best practices for the use of NIV. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). Searches included all studies involving the use of NIV or HFNC in children with PARDS or hypoxemic respiratory failure. Title/abstract review, full-text review, and data extraction using a standardized data extraction form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Out of 6,336 studies, we identified 187 for full-text review. Four clinical recommendations were generated, related to indications, timing and duration of NIV in patients with PARDS, predictors of NIV failure and need for intubation (signs and symptoms of worsening disease including pulse oximetry saturation/Fio2 ratio), and use of NIV in resource-limited settings. Six good practice statements were generated related to how and where to deliver NIV, the importance of trained experienced staff and monitoring, types of NIV interfaces, the use of sedation, and the potential complications of this therapy. One research statement was generated related to indications of HFNC in patients with PARDS. NIV is a widely used modality for the treatment of respiratory failure in children and may be beneficial in a subset of patients with PARDS. However, there needs to be close monitoring for worsening disease and NIV failure.

Use of high-flow nasal cannula in patients with COVID-19: A retrospective study

Abstract Background: During COVID-19 pandemia, the healthcare systems all over the world had to confront many different and complicated issues. One of them was the way to support the patients’ respiratory system. Generally, the HFNC therapy was applied in the past for respiratory support, but we did not have studies to establish its efficiency. Therefore, with the recent study, despite the small number of patients, an effort was made to apply the HFNC therapy so as to avoid intubation and invasive mechanical ventilation. Methods: This current study is a retrospective. Patients’ medical data admitted in the Covid – 19 ward from Agios Pavlos General hospital in Thessaloniki from October 25, 2020 to May 25, 2021 were reviewed. General clinical outcomes, the success of HFNC therapy, and related respiratory support methods were evaluated. Results: The present study included 39 patients (27 men and 12 women), whose mean age was 64,5±10,3 years old, 44% of the population had a clear medical history, and 56,4% had some comorbidities. After applying HFNC therapy, 66,7% withdrew successfully, and 33,3% were intubated. The mean time of HFNC therapy is 3,3±2,4 days, while the mean total length of hospitalization was 18,3±10,9. Conclusions: This current study describes the application of HFNC during the COVID-19 pandemia, and the conclusion is that the use of HFNC is an effective way to treat COVID-19 infected patients but under close monitoring. It had been shown that the application of HFNC can reduce the rate of intubation and mortality. Nevertheless, the conclusions of this particular study cannot be generalized.

Protocol-Driven Initiation and Weaning of High-Flow Nasal Cannula for Patients With Bronchiolitis: A Quality Improvement Initiative.

Bronchiolitis is the most common cause for nonelective infant hospitalization in the United States with increasing utilization of high-flow nasal cannula (HFNC). We standardized initiation and weaning of HFNC for bronchiolitis and quantified the impact on outcomes. Our specific aim was to reduce hospital and ICU length of stay (LOS) by 10% between two bronchiolitis seasons after implementation. A quality improvement (QI) project using statistical process control methodology. Tertiary-care children's hospital with 24 PICU and 48 acute care pediatric beds. Children less than 24 months old with bronchiolitis without other respiratory diagnoses or underlying cardiac, respiratory, or neuromuscular disorders between December 2017 and November 2018 (baseline), and December 2018 and February 2020 (postintervention). Interventions included development of an HFNC protocol with initiation and weaning guidelines, modification of protocol and respiratory assessment classification, education, and QI rounds with a focus on efficient HFNC weaning, transfer, and/or discharge. A total of 223 children were included (96 baseline and 127 postintervention). The primary outcome metric, average LOS per patient, decreased from 4.0 to 2.8 days, and the average ICU LOS per patient decreased from 2.8 to 1.9 days. The secondary outcome metric, average HFNC treatment hours per patient, decreased from 44.0 to 36.3 hours. The primary and secondary outcomes met criteria for special cause variation. Balancing measures included ICU readmission rates, 30-day readmission rates, and adverse events, which were not different between the two periods. A standardized protocol for HFNC management for patients with bronchiolitis was associated with decreased hospital and ICU LOS, less time on HFNC, and no difference in readmissions or adverse events.

Application of High-Flow Nasal Cannula in COVID-19: A Narrative Review.

Background: During the first wave of COVID-19, the large influx of severely ill patients led to insufficient availability of beds in intensive care units and a shortage of ventilators. The shortage of ventilators, high mortality of intubated patients, and high risk of infections among healthcare workers involved in intubation were the main factors that led to the prevalence of noninvasive respiratory support during the pandemic. The high-flow nasal cannula (HFNC) is a commonly used, popular form of noninvasive respiratory support. Due to its unique physiological effects, HFNC can provide a high fraction of humidified oxygen and is satisfactorily comfortable for patients with COVID-19. However, before the COVID-19 era, there was little evidence on the application of HFNC in patients with acute respiratory failure caused by viral infection. Aim: This narrative review provides an overview of recent studies on the use of HFNC in patients with COVID-19-related acute hypoxemic respiratory failure. The main topics discussed include the probability of successful use of HFNC in these patients, whether late intubation increases mortality, the availability of convenient and accurate monitoring tools, comparison of HFNC with other types of noninvasive respiratory support, whether HFNC combined with the prone position is more clinically useful, and strategies to further reduce the infection risk associated with HFNC. The implication of this study is to identify some of the limitations and research gaps of the current literature and to give some advice for future research.